Professional Documents
Culture Documents
ICN - APN Report - EN
ICN - APN Report - EN
GUIDELINES
ON ADVANCED
PRACTICE NURSING
2020
Cover photo: The Twin Bridges Nurse Practitioner
All rights, including translation into other languages, reserved. No part of this publication may be reproduced in print,
by photostatic means or in any other manner, or stored in a retrieval system, or transmitted in any form, or sold
without the express written permission of the International Council of Nurses. Short excerpts (under 300 words)
may be reproduced without authorisation, on condition that the source is indicated.
ISBN: 978-92-95099-71-5
INTERNATIONAL COUNCIL OF NURSES
GUIDELINES
ON ADVANCED
PRACTICE NURSING
2020
Mary Wambui Mwaniki
2
AUTHORS
Lead Author
Madrean Schober, PhD, MSN, ANP, FAANP
President, Schober Global Healthcare Consulting
International Healthcare Consultants
New York, NY, USA
Contributing Authors
Daniela Lehwaldt, PhD, MSc, PGDipED, BNS Joyce Pulcini, PhD, PNP-BC, FAAN, FAANP
Deputy Chair, ICN NP/APN Network Professor, George Washington University
Assistant Professor and International Liaison School of Nursing
School of Nursing and Human Sciences Washington, DC, USA
Dublin City University, Republic of Ireland
Josette Roussel, MSc, MEd, RN
Melanie Rogers, PhD Program Lead, Nursing Practice and Policy
Chair, ICN NP/APN Network Programs and Policy
Advanced Nurse Practitioner Canadian Nurses Association
University Teaching Fellow Ottawa, Canada
University of Huddersfield, U.K.
David Stewart, RN, BN, MHM
Mary Steinke, DNP, APRN-BC, FNP-C Associate Director, Nursing and Health Policy
ICN NP/APN Core Steering Group International Council of Nurses
Liaison, Practice Subgroup Geneva, Switzerland
Director Family Nurse Practitioner Program
Indiana University-Kokomo, Indiana, USA
3
ACKNOWLEDGEMENT
ICN would like to thank the following people who provided a preliminary review of the guidelines:
• Fadwa Affara, Consultant, Edinburgh, Scotland
• Fariba Al Darazi, Prior Regional Director of Nursing, WHO, Regional Office of the Eastern Mediterranean
Region, Bahrain
• Majid Al-Maqbali, Directorate of Nursing, Ministry of Health, Oman
• Michal Boyd, Nurse Practitioner/Professor, University of Auckland, New Zealand
• Lenora Brace, President, Nurse Practitioner Association of Canada
• Karen Brennan, Past President, Irish Association of Nurse Practitioners
• Denise Bryant-Lukosius, Professor, McMaster University, Canadian Centre for APN Research
• Jenny Carryer, Professor, Massey University, New Zealand
• Sylvia Cassiani, Regional Advisor for Nursing, Pan American Health Organization
• Irma H. de Hoop, Dutch Association of Nurse Practitioners, Netherlands
• Christine Duffield, Professor, University of Technology, Sydney, Australia
• Pilar Espinoza, Director, Postgraduate, research and international affairs at the health care sciences faculty
of the San Sebastián University, Chile
• Lisbeth Fagerstrom, Professor, University College of Southeast Norway
• Glenn Gardner, Emeritus Professor, Queensland University of Technology, Australia
• Nelouise Geyer, CEO, Nursing Education Association, Pretoria, South Africa
• Susan Hassmiller, Senior Advisor for Nursing, Robert Wood Johnson Foundation, USA
• Heather Henry-McGrath, President, Jamaica Association of Nurse Practitioners, International
Ambassador-American Association of Nurse Practitioners
• Simone Inkrot, Sabrina Pelz, Anne Schmitt, Christoph von Dach, APN/ANP Deutches Netzwerk G.E.V.,
Germany and Switzerland
• Anna Jones, Senior Lecturer, School of Healthcare Sciences, College of Biomedical and Life Sciences,
Cardiff University, Wales
• Elke Keinhath, Advanced Practice Nurse, APN/ANP Deutches Netzwerk G.E.V., Germany
• Mabedi Kgositau, International Ambassador-American Association of Nurse Practitioners,
University of Botswana
• Sue Kim, Professor, College of Nursing Yonsei University, South Korea
• Karen Koh, Advanced Practice Nurse, National University Hospital, Singapore Nursing Board
• Katrina Maclaine, Associate Professor, London South Bank University
• Vanessa Maderal, Adjunct Professor, University of the Philippines
• Donna McConnell, Lecturer in Nursing, Ulster University, Northern Ireland
• Evelyn McElhinney, Senior lecturer, Programme Lead MSc Nursing: Advancing Professional Practice,
Glasgow Caledonian University, Scotland
• Arwa Oweis, Regional Advisor for Nursing, WHO, Regional Office of the Eastern Mediterranean Region,
Cairo, Egypt
• Jeroen Peters, Program Director, Nimigen University, Netherlands
• Andrew Scanlon, Associate Professor, Montclair University, Australia
• Bongi Sibanda, Advanced Nurse Practitioner, Anglophone Africa APN Coalition Project, Zimbabwe
• Anna Suutaria, Head of International Affairs, Finnish Nurses’ Association
• Peter Ullmann, Chair, APN/ANP Deutsches Netzwerk G.E.V., Germany
• Zhou Wentao, Director, MScN Programme, National University of Singapore
• Kathy Wheeler, Co-chair International Committee, American Association of Nurse Practitioners
• Frances Wong, Professor, Hong Kong Polytechnic University
4
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
TABLE OF CONTENTS
List of Tables/Figures..............................................................................................................................................6
Glossary of terms....................................................................................................................................................6
Foreword..................................................................................................................................................................7
Abstract....................................................................................................................................................................8
References.............................................................................................................................................................27
Appendices............................................................................................................................................................33
Appendix 1: Credentialing Terminology .......................................................................................................33
Appendix 2: The International Context and Country Examples of the CNS..............................................33
Appendix 3: The International Context and Country Examples of the NP.................................................35
Appendix 4: Country exemplars of adaptations or variations of CNS and NP..........................................38
5
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
LIST OF TABLES/FIGURES
Table 1: Characteristics delineating Clinical Nurse Specialist practice
Table 2: Differentiating a Specialised Nurse and a Clinical Nurse Specialist
Table 3: Characteristics of Clinical Nurse Specialists and Nurse Practitioners
Table 4: Similarities between Clinical Nurse Specialists and Nurse Practitioners
Table 5: Differentiating the Clinical Nurse Specialist and the Nurse Practitioner
Figure 1: Progression from Generalist Nurse to Clinical Nurse Specialist
Figure 2: Distinction between Clinical Nurse Specialist and Nurse Practitioner
GLOSSARY OF TERMS
Advanced Nursing Practice (ANP) Advanced Practice Registered Nurse (APRN)
Advanced Nursing Practice is a field of nursing that APRN, as used in the USA, is the title given to a nurse
extends and expands the boundaries of nursing’s who has met education and certification requirements
scope of practice, contributes to nursing knowledge and obtained a license to practice as an APRN in one
and promotes advancement of the profession (RNABC of four APRN roles: certified registered nurse anesthe-
Policy Statement, 2001). ANP is ‘characterised by the tist (CRNA), certified nurse-midwife (CNM), Clinical
integration and application of a broad range of theoret- Nurse Specialist (CNS), and certified Nurse Practitioner
ical and evidence-based knowledge that occurs as part (CNP) (APRN Consensus Model, 2008).
of graduate nursing education’ (ANA, 2010 as cited in
Hamric & Tracy, 2019, p. 63). Clinical Nurse Specialist (CNS)
A Clinical Nurse Specialist is an Advanced Practice
Advanced Practice Nurse (APN) Nurse who provides expert clinical advice and care
An Advanced Practice Nurse (APN) is a generalist or based on established diagnoses in specialised clin-
specialised nurse who has acquired, through additional ical fields of practice along with a systems approach in
graduate education (minimum of a master’s degree), practicing as a member of the healthcare team.
the expert knowledge base, complex decision-making
skills and clinical competencies for Advanced Nursing Nurse Practitioner (NP)
Practice, the characteristics of which are shaped by A Nurse Practitioner is an Advanced Practice Nurse
the context in which they are credentialed to practice who integrates clinical skills associated with nursing
(adapted from ICN, 2008). The two most commonly and medicine in order to assess, diagnose and man-
identified APN roles are CNS and NP. age patients in primary healthcare (PHC) settings and
acute care populations as well as ongoing care for
Advanced Practice Nursing (APN) populations with chronic illness.
Advanced Practice Nursing, as referred to in this paper,
is viewed as advanced nursing interventions that influ-
ence clinical healthcare outcomes for individuals,
families and diverse populations. Advanced Practice
Nursing is based on graduate education and prepar
ation along with the specification of central criteria and
core competencies for practice (AACN, 2004, 2006,
2015; Hamric & Tracy, 2019).
6
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
FOREWORD
2020 has been named The International Year of the This is clearly evident in Advanced Practice Nursing
Nurse and Midwife by the World Health Organization. It (APN). Whilst this appears to be a relatively recent con-
celebrates both the professionals who provide a broad cept, distinct patterns can be seen in the transition of
range of essential health services to people every- specialty practice into Advanced Practice Nursing over
where as well as the bicentenary of the birth of Florence the last 100 years. (Hanson & Hamric 2003)
Nightingale. However, the International Council of
Nurses (ICN) recognises that this year needs to be Over this time there has been growing demand for APN
more than just a celebration. It needs to be a time of globally; however, many countries are in different stages
action and commitment by governments, health sys- of development of these roles as part of the nursing
tems and the public to support the capacity, capability workforce. In addition, many APN positions have devel-
and empowerment of the nursing profession to meet the oped on an ad-hoc basis with varying responsibilities,
growing demands and health needs of individuals and roles and nomenclature. The scope of practice is often
communities. Without the nursing profession, millions diverse and heterogenous across global regions. Often
of people around the world will not be able to access pathways to entry and practice boundaries can be
quality, safe and affordable healthcare services. As the blurred, poorly understood and sometimes contested.
largest group of healthcare workers providing the vast This has led to confusion amongst policy makers,
majority of care, particularly in the primary care setting, health professionals and the public at large.
it is not surprising that the nursing workforce investment
can yield significant improvement in patient outcomes. To seize the richness and opportunities afforded by
Advanced Practice Nursing, it is important that the pro-
Throughout history, we can see the continual evolution fession provide clear guidance and direction. ICN has
of the nursing profession in order to address the health, been a leader in the development of the profession-
societal and person-centred care challenges. alisation of nursing since its very beginning in 1899.
It has provided guidance on a range of topics related
It is for this reason, that as the global voice of nursing, to nursing including the most widely used definition of
ICN has been calling for investment in nursing, and in APN to date.
particular APN, to address global health challenges. As
a Commissioner on the WHO High Level Commission ICN is seeking to build on this work through the release
on Noncommunicable Diseases (NCDs), the ICN of these new guidelines on Advanced Practice Nursing.
President witnessed the global community wrestle with Undertaken with the leadership support of the ICN
solutions to address the need to reduce mortality from APN/NP Network, these guidelines have undergone an
NCDs by 30% by 2030. What became clear was that extremely rigorous and robust global consultation pro-
the status quo cannot continue and that governments cess. They aim to support the current and future devel-
need to reorient their health systems and support opment of APN across countries in order to improve the
the health workforce, particularly APNs, to effectively quality of service that our profession offers to individu-
respond to promotion, prevention and management als and communities.
of disease. This is echoed in the Astana Declaration
with the visionary pursuit of achieving Health for All Our hope is that through the development of these
through Primary Health Care. The foundation for this guidelines, some of the barriers and walls that have hin-
is nurses working to their full scope of practice. We dered the nursing profession can be torn down. These
boldly declare, that APNs are an effective and efficient guidelines will hopefully support the profession, enable
resource to address the challenges of accessible, safe a clearer understanding and assist in the continual evo-
and affordable health care. lution of APN. People around the world have the right
to quality, safe and affordable healthcare. Advanced
Practice Nurses are one of the solutions to making this
happen.
7
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
ABSTRACT
In order to meet changing global population needs and (ICN 2008a). Since that time, worldwide development
consumer expectations, healthcare systems worldwide has increased significantly and simultaneously this
are under transformation and face restructuring. As field of nursing has matured. ICN felt that a review of
systems adapt and shift their emphasis in response to its position was needed to assess the relevance of the
the disparate requests for healthcare services, oppor- definition and characteristics offered in 2002. This guid-
tunities emerge for nurses, especially the APN, to meet ance paper defines diverse elements such as assump-
these demands and unmet needs (Bryant-Lukosius et tions and core components of the APN. The attributes
al. 2017; Carryer et al. 2018; Cassiani & Zug 2014; and descriptors presented in this paper are intended
Cooper & Docherty 2018; Hill et al. 2017; Maier et to promote a common vision to continue to enable a
al. 2017). greater understanding by the international nursing and
healthcare communities for the development of roles
In 2002, the International Council of Nurses (ICN) pro- commonly identified as Clinical Nurse Specialist (CNS)
vided an official position on Advanced Practice Nursing and Nurse Practitioner (NP).
Mary Wambui Mwaniki
8
Chapter One: Advanced Practice Nursing
CHAPTER ONE
1 In this paper, the emphasis is on the characteristics and professional standard of the CNS. The title of CNS is used to represent the role or level of nursing
as it is a widely identified category of Advanced Practice Nursing worldwide.
2 As per ICN’s definition of a nurse, the nurse is a person who has completed a programme of basic, generalised nursing education and is authorised by the
appropriate regulatory authority to practice nursing in his/her own country. https://www.icn.ch/nursing-policy/nursing-definitions
9
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
10
Chapter One: Advanced Practice Nursing
11
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
CHAPTER TWO
3 It is acknowledged there are countries with Clinical Nurse Consultants (CNC) whose practice is viewed to be consistent with CNS practice
(Bryant-Lukosius & Wong, 2019; Carryer et al. 2018; Gardner et al. 2013; Gardner et al. 2016). The use of CNC is country specific and at times
used interchangeably with CNS, however, this guidance paper focuses on identifying the CNS.
12
Chapter Two: The Clinical Nurse Specialist (CNS)
• Clinical Nurse Specialists (CNSs) are professional nurses with a graduate level preparation
(master’s or doctoral degree).
• CNSs are expert clinicians who provide direct clinical care in a specialised area of nursing practice.
Specialty practice may be defined by population (e.g. pediatrics, geriatrics, women’s health); clinical
setting (e.g. critical care, emergency); a disease/medical subspecialty (e.g. oncology, diabetes);
type of care (psychiatric, rehabilitation); or type of problem (e.g. pain, wound, incontinence).
• Clinical practice for a specialty population includes health promotion, risk reduction, and management
of symptoms and functional problems related to disease and illness.
• CNSs provide direct care to patients and families, which may include diagnosis and treatment of disease.
• CNSs practice patient/family centred care that emphasises strengths and wellness over disease or deficit.
• CNSs influence nursing practice outcomes by leading and supporting nurses to provide scientifically
grounded, evidence-based care.
• CNSs implement improvements in the healthcare delivery system (indirect care) and translate high-quality
research evidence into clinical practice to improve clinical and fiscal outcomes.
• CNSs participate in the conduct of research to generate knowledge for practice.
• CNSs design, implement and evaluate programmes of care and programmes of research that address
common problems for specialty populations. (Fulton & Holly April 2018)
While CNSs were originally introduced in hospitals Although nurses who practice in various specialties
(Delamaire & LaFortune 2010), the role has evolved (e.g. intensive care unit, theatre/surgery, palliative care,
to provide specialised care for patients with com- wound care, neonatal, gerontology) may consider them-
plex and chronic conditions in outpatient, emergency selves at times to be specialised nurses, the designated
department, home, community and long-term care CNS has a broader and extended range of accountabil-
settings (Bryant-Lukosius & Wong 2019; Kirkpatrick ity and responsibility for improvements in the healthcare
et al. 2013). Commonly, the provision of healthcare delivery system, including an advanced level clinical
services by a CNS includes the combination of direct specialty focus. Based on postgraduate education at
and indirect healthcare services (refer to Section 2.3) a minimum of a master’s or doctoral degree, the CNS
based on nursing principles and a systems perspective acquires additional in-depth knowledge, critical thinking
(CNA 2014; NACNS 2004; NCNM 2007). It is acknow and decision-making skills that provide the foundation
ledged that indirect services of the CNS are highly val- for an advanced level of practice and decision making.
ued along with direct clinical care and should be taken
into consideration when defining scope of practice.
13
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
In defining the scope of practice for the CNS, identifi- • Indirect Care involves indirect provision
cation of core competencies includes levels of direct of care through activities that influence the care
and indirect nursing care. These levels of care include of patients, but do not involve direct engagement
assisting other nurses and health professionals in with populations. Examples include developing
establishing and meeting healthcare goals of individ- evidence-based/evidence-informed guidelines
uals and a diverse population of patients (CNA 2014; or protocols for care and staff development
NACNS 2004). activities. A CNS providing indirect care:
• Direct Care involves direct interaction with patients, • serves as a consultant to other nurses
families and groups of patients to promote health and healthcare professionals in managing
or well-being and improve quality of life. Direct care: highly complex patient care problems
• integrates advanced knowledge of wellness, and in achieving quality, cost-effective outcomes
illness, self-care, disease and medical for populations across healthcare settings;
therapeutics in a holistic assessment of people • provides leadership in appropriate use
while focusing on the nursing diagnosis of research/evidence in practice innovations
of symptoms, functional problems and risk to improve healthcare services;
behaviours that have etiologies requiring nursing • develops, plans and directs programmes of care
interventions to prevent, maintain or alleviate; for individuals and populations and provides
• utilises assessment data, research and theoretical direction to nursing personnel and others
knowledge to design, implement and evaluate in these programmes of care;
nursing interventions that integrate delegated • evaluates patient outcomes and
medical treatments as needed; and cost-effectiveness of care to identify needs
• prescribes or orders therapeutic interventions. for practice improvements within the clinical
specialty or programme; and
• serves as a leader of multidisciplinary groups in
designing and implementing alternative solutions
to patient care issues across the continuum
of care. (CNA 2014; NACNS 2004)
14
Chapter Two: The Clinical Nurse Specialist (CNS)
(WHO-EMRO 2018: 7)
4 In its Regulation Series, ICN provides a Nursing Care Continuum Framework & Competencies (ICN 2008b) and defines the specialised nurse as a nurse
prepared beyond the level of a generalist nurse, authorised to practice as a specialist in a branch of the nursing field.
15
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
One criterion for designating a specialty for nursing the CNS the possibility to move more easily within the
practice stipulates that the specialty is officially rec- member states of Europe. Consistent with the guide-
ognised and supported by the health system in the lines in this paper, ESNO identifies the CNS as an
country. In addition, levels of specialist nursing practice APN, educated within a clinical specialty at a master’s,
progress to an advanced level of specialisation such post-master’s or doctoral level.
as the CNS based on completion of a clinical master’s
degree in the area of specialisation, and using the title From the perspective of workforce development and
Registered Advanced Practice Nurse with area of spe- healthcare reform, it is understood that delivery of
cialty indicated. For example, Registered Advanced healthcare services requires a range of personnel
Practice Cardiac Nurse (WHO-EMRO 2018). and that there would be larger numbers of special-
ised nurses in staff positions versus CNSs. CNSs with
Similarly, the European Specialist Nurses Organization advanced clinical expertise and a graduate degree
(ESNO 2015) recommends development of compe- (minimum of master’s degree) in a clinical specialty
tencies for the CNS to clarify the position and prac- function collaboratively within healthcare teams. They
tice of this nurse in Europe. This recommendation use a systems approach to coordinate directives of
includes building a framework corresponding to the specialty care in addition to providing direct healthcare
features of the specialty in which the CNS will practice. services. Table 2 below is a useful tool to distinguish the
Identification of consistent qualifications would enable characteristics of the specialised nurse and the CNS.
16
Chapter Two: The Clinical Nurse Specialist (CNS)
Figure 1 depicts the progression from that of a gen- themselves as a CNS. The additional education and
eralist nurse to a CNS and then educated in a CNS clinical expertise gained with an academic degree has
specific master’s degree programme. This progression the potential to further assure quality of care for diverse
provides recognition of the foundation of specialised populations. Based on standardised and accredited
clinical expertise based on the foundation of a general- academic programmes, this level of professional devel-
ist nursing education. A generalist nurse may proceed opment is viewed as essential when seeking to deliver
to enter a CNS programme directly if the candidate optimal safe and high-quality healthcare by enhancing
meets national and academic criteria for CNS prep academic rigor, scientific reasoning and critical thinking.
aration. Completion of a minimum of a master’s degree
provides enhanced professional as well as clinical cred- Refer to Appendix 2, p. 33 for country exemplars of the
ibility for the nurse, who progresses and distinguishes Clinical Nurse Specialist.
Carolyn Jones
17
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
CHAPTER THREE
18
Chapter Three: The Nurse Practitioner
is one way of informing the public, administrators and The AANP scope of practice position paper also stipu-
other healthcare professionals about the role in order to lates the educational level for the NP and notes a level
differentiate the qualified NP from other clinicians who of accountability and responsibility associated with pro-
are not adequately prepared for NP practice or have not viding advanced high-quality, ethical care to the public.
been authorised to practice in this capacity.
The Nursing Council of New Zealand (NCNZ 2017a:1)
ICN position on the Nurse Practitioner scope describes the following NP scope of practice and links
of practice the scope to six competencies that define the know
A scope of practice for the NP describes the range ledge, skills and attitudes required of them:
of activities associated with recognised professional
responsibilities consistent with regulation and policy in
the setting(s) in which the NP practices. Understanding
the country/state/provincial context in which the NP will Nurse practitioners have advanced education, clinical
practice is fundamental when defining a scope of practice training and the demonstrated competence and legal
for NP provision of healthcare services. In addition, it is authority to practice beyond the level of a registered
essential that development of a scope of practice focuses nurse. Nurse practitioners work autonomously and in
on the activities of an NP that underpins the more complex collaborative teams with other health professionals to
knowledge and skill sets of NP practice. ICN takes the fol- promote health, prevent disease, and improve access
lowing position for a Nurse Practitioner Scope of Practice: and population health outcomes for a specific patient
group or community. Nurse practitioners manage epi-
The Nurse Practitioner possesses advanced health sodes of care as the lead healthcare provider in part-
assessment, diagnostic and clinical management nership with health consumers and their families/
skills that include pharmacology management whanau. Nurse practitioners combine advanced nurs-
based on additional graduate education (minimum ing knowledge and skills with diagnostic reasoning and
standard master’s degree) and clinical education therapeutic knowledge to provide patient-centred
that includes specified clinical practicum in order to healthcare services including the diagnosis and man-
provide a range of healthcare services. The focus of agement of health consumers with common and com-
NP practice is expert direct clinical care, managing plex health conditions. They provide a wide range of
healthcare needs of populations, individuals assessment and treatment interventions, ordering and
and families, in PHC or acute care settings with interpreting diagnostic and laboratory tests, prescribing
additional expertise in health promotion and disease medicines within their area of competence, and
prevention. As a licensed and credentialed clinician, admitting and discharging from hospital and other
the NP practices with a broader level of autonomy healthcare service/settings. As clinical leaders, they
work across healthcare settings and influence health
beyond that of a generalist nurse, advanced in-depth
service delivery and the wider profession. Nurse
critical decision-making and works in collaboration
Practitioner Competencies are presented next:
with other healthcare professionals. NP practice
may include but is not limited to the direct referral 1. Demonstrates safe and accountable Nurse
of patients to other services and professionals. NP Practitioner practice incorporating strategies
practice includes integration of education, research to maintain currency and competence.
and leadership in conjunction with the emphasis on 2. Conducts comprehensive assessments
direct advanced clinical care. and applies diagnostics reasoning to identify
health needs/problems and diagnoses.
Examples of Nurse Practitioner scope of practice 3. Develops, plans, implements and evaluates
from three countries therapeutic interventions when managing
Each country where the NP is well developed needs a episodes of care.
robust scope of practice. Three examples of NP scopes 4. Consistently involves the health consumer
of practice are presented here to provide guidance and to enable their full partnership in decision making
dialogue on this topic. Firstly, the American Association and active participation in care.
of Nurse Practitioners’ (AANP) Scope of Practice for 5. Works collaboratively to optimise health outcomes
Nurse Practitioners states that: for health consumers/population groups.
6. Initiates and participates in activities that support
safe care, community partnership and population
improvements.
Nurse Practitioners assess, diagnose, treat and manage
acute episodic and chronic illnesses. They order, con-
duct, supervise and interpret diagnostic and laboratory
tests, prescribe pharmacological agents and non-
pharmacologic therapies as well as teach and counsel
patients. NPs are experts in health promotion and dis-
ease prevention. As licensed clinicians, NPs practice
autonomously and in coordination with other health care
professionals. They may serve as healthcare research-
ers, interdisciplinary consultants and patient advocates,
in addition to providing a wide range of health care ser-
vices to individuals, families, groups and communities.
(AANP, 2015)
19
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
In the Republic of Ireland, Registered Advanced Nurse In the Republic of Ireland, this description of autonomy
Practitioners (RANP) also work within an agreed scope is designated for both the ANP and Advanced Midwife
of practice and meet established criteria set by the Practitioner (AMP).
Nursing and Midwifery Board of Ireland (NMBI 2017).
Autonomy for the NP has been highlighted within the This section emphasises the significance of establish-
scope of practice by designating that the Advanced ing a scope of practice for NPs and provides examples
Nurse Practitioner (ANP): to consider when developing an NP scope of practice.
Identifying a scope of practice is sensitive to country
context and the healthcare settings in which the NPs
will practice. In addition, the educational programme
…is accountable and responsible for advanced levels of and curriculum design should be in alignment with the
decision-making which occur through management of scope of practice and competencies expected of the
specific patient/client caseload. ANPs may conduct com- NP. This is discussed next in Section 3.5.
prehensive health assessment and demonstrate expert
skill in the clinical diagnosis and treatment of acute and/
or chronic illness from within a collaboratively agreed
scope of practice framework alongside other healthcare
professionals. The crucial factor in determining Advanced
Nursing Practice, however, is the level of decision-
making and responsibility rather than the nature or diffi-
culty of the task undertaken by the practitioner. Nursing
or midwifery knowledge and experience should continu-
ously inform the ANPs/AMPs decision-making, even
though some parts of the role may overlap the medical or
other healthcare professional role.
20
Chapter Three: The Nurse Practitioner
All-purpose or nonspecific master’s degree nursing programmes may be adapted to include additional skills
programmes are not a recommended pathway for specific to NP practice including advanced physical
NPs. Master’s degree education related to nursing assessment, advanced clinical reasoning and diagnos-
management, nursing research or nursing education tic decision-making, pharmacology/pharmacokinetics,
alone is not considered sufficient preparation for NPs. clinical and professional leadership, and practice-based
However, as the role evolves, existing master’s level research (NCNZ 2009; NMBI 2015a; NMBI 2017).
21
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
CHAPTER FOUR
DISTINGUISHING THE CLINICAL
NURSE SPECIALIST AND THE NURSE
PRACTITIONER
The origins of Advanced Practice Nursing as discussed in Chapters 2 and 3 provide historical backgrounds for the
CNS and NP, noting differences in stages of early development. The emergence of Advanced Practice Nursing
worldwide and the introduction of the concepts of the CNS and APN have resulted in robust discussions attempting
to identify the distinguishing characteristics of these new roles and levels of nursing practice. Since the mid-1990s
(Dunn 1997) and with more recent and parallel development internationally, the definitive characteristics of the
CNS and NP have become blurred. Despite this, the two roles remain largely distinct, albeit with some overlap
(Rushforth 2015; Tracy & Sendelbach 2019). This section endeavours to distinguish and clarify traits representative
of the CNS and NP.
The CNS is an expert clinician with a specialised area of practice identified in terms of population, setting, disease
or medical subspecialty, type of care or problem that includes a systems perspective to provision of healthcare
services (NACNS 2018). The focus of NP practice emphasises a population focus mainly in PHC but that now
includes both acute care and PHC (AACN Certification Corporation 2011). Bryant-Lukosius (2004 & 2008) clarified
the essential distinctions between the CNS and the NP through an Advanced Practice Nursing continuum model,
emphasising how the CNS focuses more on indirect care supporting clinical excellence from a systems approach
while the NP focuses more on direct patient care within diverse clinical settings.
Source: Bryant-Lukosius, D. (2004 & 2008). The continuum of Advanced Practice Nursing roles. Unpublished
document.
A recent national study comparing CNSs and NPs in in direct clinical care was high for both the CNS and NP,
Canada lends support to the above illustration (Bryant- but differences in scope of practice were reflected in
Lukosius et al. 2018). Results from this study demon- greater NP involvement in diagnosing, prescribing and
strated that while there are many common features, the treating various conditions or illness. Similar to these
main differences between the CNS and NP is related to findings, additional studies (Donald et al. 2010; Carryer
greater CNS involvement in non-clinical (indirect) activ- et al. 2018) highlight that NPs engage in direct care
ities related to support of systems, education, publica- activities to a greater extent than CNSs.
tion, professional leadership and research. Involvement
22
Chapter Four: Distinguishing the Clinical Nurse Specialist and the Nurse Practitioner
23
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
Defined scope of practice in an identified specialty Comprehensive scope of practice specific to the NP
with activities that include prescribing, diagnosis
& treatment management
Provides direct and indirect care usually to patients Commonly provides direct clinical care to patients
with an established diagnosis with un-diagnosed conditions in addition to
providing ongoing care for those with an already
established diagnosis
Works within a specialist field of practice Works generically within a variety of fields
of practice and settings
Works in defined practice populations Works with multiple diverse practice populations
(e.g. oncology, pain management, cardiology)
Works autonomously and collaboratively in a team, Works autonomously and in collaboration with other
using a systems approach, with nursing personnel healthcare professionals
or other healthcare providers and healthcare
organisations
Frequent shared clinical responsibility with other Assumes full clinical responsibility and management
health care professionals of their patient population
Works as a consultant to nurses and other health Conducts comprehensive advanced health
care professionals in managing complex patient assessments and investigations in order to make
care problems differential diagnoses
Provides clinical care related to an established Initiates and evaluates a treatment management
differentiated diagnosis plan following an advanced health assessment
and investigation based on conduct of differential
diagnoses
Influences specialist clinical and nursing practice Engages in clinical leadership, education
through leadership, education and research and research
Evaluates patient outcomes to identify Frequently has the authority to refer and admit
and influence system clinical improvements patients
May or may not have some level of prescribing Commonly has prescribing authority
authority in a specialty
24
Chapter Four: Distinguishing the Clinical Nurse Specialist and the Nurse Practitioner
• Provide safe and competent patient care through a designated role or level of nursing
• Have acquired the ability to apply the theoretical and clinical skills of Advanced Practice Nursing utilising
research, education, leadership and diagnostic clinical skills
• Have defined competencies and standards which are periodically reviewed for maintaining currency
in practice
• Are influenced by the global, social, political, economic and technological milieu
• Recognise their limitations and maintain clinical competencies through continued professional
development
25
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
Table 5: Differentiating the Clinical Nurse Specialist and the Nurse Practitioner
Definition Expert advanced practice clinicians Autonomous clinicians who are able
providing direct complex specialty to diagnose and treat conditions based
care along with a systems approach on evidence-informed guidelines
to the provision of healthcare services (Refer to Section 3.3)
(Refer to Section 2.3)
Scope of Specialty practice aimed
to ensure and Comprehensive healthcare practice,
Practice develop the quality of nursing, foster autonomous examination and assessment
Job the implementation of evidence- based of patients that includes initiating
Description nursing and support the hospital or treatment and developing a management
organisation’s strategic plan for provision plan. Management commonly includes
of healthcare services by providing direct authority to prescribe medications and
and indirect healthcare services. The therapeutics, and conducting referrals
CNS provides leadership in advancing along with monitoring acute and chronic
nursing practice including research and health issues, primarily in direct healthcare
interdisciplinary education (Refer to services. Practice includes integration
Section 2.3) of education, research and leadership in
conjunction with the emphasis on direct
clinical care. (Refer to Section 3.4)
Work Commonly based in hospital or healthcare Commonly based in PHC and other out
settings institutional settings with a specialty focus of hospital settings or acute care
In taking this position, ICN recognises the continued level of nursing. Topics that warrant further in-depth dis-
need to present guidance for discussion in order to cussion include issues of governance, education and
meet the changing healthcare demands of diverse ongoing research within and between countries, along
populations and associated healthcare systems along with exploration of Advanced Practice Nursing beyond
with the changing dimensions of nursing practice. This that of the CNS and NP.
guidance paper summarises the current situation inter-
nationally in respect to the CNS and NP and provides Refer to Appendix 4 for exemplars where countries use
a foundation for moving forward. Advanced Practice a combination of the concepts of CNS and NP. In sev-
Nursing will continue to progress in its development eral cases the title used is Advanced Practice Nurse
and these professionals should have formal education when combining attributes of the CNS and NP.
that responds to the highest standards of the role or
26
References
REFERENCES
American Association of Colleges of Nursing (AACN) (undated). AACN Statement of Support for Clinical Nurse
Specialists.
American Association of Colleges of Nursing (AACN) Certification Corporation (2011). ppt accessed 24 October 2018
from www.aacn.org media website.
American Association of Nurse Practitioners (AANP) (2015). Scope of Practice for Nurse Practitioners. Position
Paper.
American Association of Nurse Practitioners (AANP) (2018). What’s an NP? Accessed September 5, 2018 from
www.aanp.org/all-about-nps/what-is-an-np.
American Nurses Association (2004). Nursing: Scope & Standards of Practice. Washington, DC: American Nurses
Association.
American Nurses Association (2015). Nursing: Scope and Standards of Practice, 3rd. Ed. Silver Spring, MD; ANA.
ISBN: 978-1-55810-619-2; PUB# 9781558106192.
APRN Consensus Group Work Group & NCSBN APRN Advisory Committee. (2008). Consensus Model for APRN
regulation: Licensure, Accreditation, Certification, and Education. Available at: http://www.nonpf.org/associa-
tions/10789/files/APRNConsensusModelFinal09.pdf.
Barton TD, Allan D (2015). Advanced Practice: Changing Healthcare in a Changing World. London: Palgrave/
Macmillan Publishers Limited.
Barton D, East L (2015). The Evolution of Advanced Nursing Practice. In T.D. Barton, D. Allan (Eds.) Advanced
Nursing Healthcare in a Changing World. London: Palgrave/Macmillan Publishers Limited. pp. 1 – 19.
Begley C, Murphy K, Higgins A, Elliott N, Lalor J, Sheerin F, Coyne I, Comiskey C, Normand C, Casey C, Dowling M,
Devane D, Cooney A, Farrelly F, Brennan M, Meskell P, MacNeela P (2010). Evaluation of Clinical Nurse and
Midwife Specialist and Advanced Nurse and Midwife Practitioner Roles in Ireland (SCAPE) Final Report. National
Council for the Professional Development of Nursing and Midwifery in Ireland, Dublin.
Brown-Brumfield D, DeLeon A (2010). Adherence to a medication safety protocol: Current practice for labeling
medications and solutions on the sterile field. Association of Operating Room Nurses Journal, 91, pp. 610 – 617.
Bryant-Lukosius D (2004 & 2008). The Continuum of Advanced Practice Nursing Roles. Unpublished document.
Bryant-Lukosius D, Carter N, Kilpatrick K, Martin-Misener R, Donald F, Kaasalainen S, DiCenso A (2010). The Clinical
Nurse Specialist in Canada. Nursing Leadership, 23 (Special Issue), 140-166. doi:10.12927/cjnl.2010.22273.
Bryant-Lukosius D, Cosby R, Bakker D, Earle C, Burkoski V (2015). Practice Guideline on the Effective Use of
Advanced Practice Nurses in the Delivery of Adult Cancer Services in Ontario. Toronto: Cancer Care Ontario.
Available at: https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/2166.
Bryant-Lukosius D, Martin-Misener R (2016). ICN Policy Brief Advanced Practice Nursing: An Essential Component
of Country Level Human Resources for Health. Geneva.
Bryant-Lukosius D, Valaitis R, Martin-Misener R, Donald F, Moran Pena L, Brosseau L (2017). Advanced Practice
Nursing: A strategy for achieving universal health coverage and universal access to health. Revista Latino-
americano de Enfermagem, 25, e2826, doi: 10.1590/1518-8345.1677.2826.
27
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
Bryant-Lukosius D, Wong FKY (2019). International Development of Advanced Practice Nursing. In M.F. Tracy
& E.T. O’Grady (eds). Advanced Practice Nursing: An Integrative Approach, 6th edition, pp. 129-141, St. Louis,
Missouri: Elsevier.
Canadian Nurses Association (CNA) (2008). Advanced Nursing Practice: A National Framework. Ottawa: Author.
Canadian Nurses Association (CNA) (2014). Core Competencies for the Clinical Nurse Specialist in Canada.
Ottawa: Author.
Canadian Nurses Association (CNA) (2016a). The Canadian Nurse Practitioner Initiative: A 10 year Retrospective.
Ottawa: Author.
Canadian Nurses Association (CNA) (2016b). Position Statement Clinical Nurse Specialist. Ottawa: Author.
Canadian Nurses Association (CNA) (2018) Nurse Practitioners. Retrieved 8 September 2018 from: https://cna-
aiic.ca/en/professional-development/advanced-nursing-practice/nurse-practitioners.
Canadian Nurses Association (CNA) (2019) Advanced Practice Nursing: A Pan-Canadian Framework. Author:
CNA, Ottawa, Canada.
Cary AH, Smolenski MC (2018). Credentialing and Clinical Privileges for the Advanced Nurse. In L. Joel (Ed.)
Advanced Practice Nursing: Essentials for Role Development. 4th Edition. pp. 100 – 115, Philadelphia: F.A. Davis.
Carryer J, Wilkinson J, Towers A, Gardner G (2018). Delineating Advanced Practice Nursing in New Zealand:
A national survey. International Nursing Review, 65(1) pp. 24 – 32.
Cassiani SHDB, Zug KE (2014). Promoting the Advanced Nursing Practice role in Latin America. Revista Brasileira
de Enfermagen. 67(5) pp. 673-674. doi: 10.1590/0034-7167.2014670501.
Chan GK, Cartwright CC (2014). The Clinical Nurse Specialist. In A.B. Hamric, C.M. Hanson, M.F. Tracy, E.T.
O’Grady (Eds.) Advanced Practice Nursing: An Integrative Approach. 5th Edition. St. Louis: Elsevier Saunders.
pp. 359 – 395.
Chavez K, Dwyer A, Ramelet A (2018). International practice settings, interventions and outcomes of Nurse
Practitioners in geriatric care: A scoping review. International Journal of Nursing Studies. 78, pp 61-75. doi:
10.1016/j.ijnurstu.2017.09.010. Epub 2017 Sep 18.
Cockerham AZ, Keeling AW (2014). A Brief History of Advanced Practice Nursing in the United States. In A.B. Hamric,
C.M. Hanson, M.F. Tracy, E.T. O’Grady (Eds.) Advanced Practice Nursing: An Integrative Approach. 5th Edition.
St. Louis: Elsevier Saunders. pp. 1 – 26.
Cook O, McIntyre M, Recoche K (2015). Exploration of the role of specialist nurses in the care of women with
gynaecological cancer: A systematic review. Journal of Clinical Nursing, 24(5-6), pp. 683-695.
Cooper MA, Docherty E (2018). Transforming the landscape. Comment. British Journal of Nursing, 27(21) p. 1216.
Delamaire M, Lafortune G (2010) Nurses in advanced roles: A description and evaluation of experiences in 12 devel-
oped countries. OECD Working Health Working Papers No. 54, OECD Publishing. doi.org/10.1787/5kmbrcfms5g7-en.
Dunn L (1997). A literature review of advanced clinical nursing practice in the United States. Journal of Advanced
Nursing 25: pp. 814-819.
Dunphy LM, Flinter MM, Simmonds KE (2019). The primary care Nurse Practitioner. In M. F. Tracy, E.T. O’Grady
(eds), Advanced Practice Nursing: An integrative approach, 6th Edition, St. Louis, Missouri: Elsevier Inc.
28
References
European Specialist Nurses Organizations (ESNO) (2015). Competences of the Clinical Nurse Specialist (CNS):
Common plinth of competences for the common training framework of each specialty. Version 1, 17-10-2015.
Fagerström L (2009). Developing the scope of practice and education for Advanced Practice Nurses in Finland.
International Nursing Review, 56, pp 269‐272.
Flanders S, Clark AP (2010). Interruptions and medication errors. Clinical Nurse Specialist, 24, pp. 281 – 285.
Finnish Nurses Association (2016). New roles for nurses – quality to future social welfare and health care services.
English translation accessed September 8, 2018. Available at: https://sairaahoitajat.fi/wp-content/uploads/2018/06/
apn_raportti_eng_valmis_pieni.pdf.
Fulton J, Holly V (2018). Characteristics of the CNS role and practice. Personal communication April 2018.
Gardner G, Chang AM, Duffield C, Doubrovsky A (2013). Delineating the practice profile of Advanced Practice
Nursing: a cross-sectional survey using the modified Strong Model of advanced practice. Journal of Advanced
Nursing, 69(9) pp. 1931-1942.
Gardner G, Duffield C, Doubrovsky A & Adams M (2016). Identifying advanced practice: A national survey of a
nursing workforce. International journal of nursing studies, 55, pp. 60-70.
Gardner G, Duffield C & Gardner A (2017). The Australian Advanced Practice Nursing Self-Appraisal Tool (The
ADVANCE Tool). Queensland University of Technology.
Gardner G, Duffield C, Doubrovsky A, Adams M (2015). Identifying advanced practice: a national survey of a nurs-
ing workforce. International Journal of Nursing Studies, 55 pp. 60-70.
Government of Ireland (1998). Report of the Commission on Nursing. A Blueprint for the Future. Available at:
https://health.gov.ie/wp-content/uploads/2014/03/Report-of-The-Commision-on-Nursing.pdf.
Hamric AB, Tracy MF (2019). A definition of Advanced Practice Nursing. In M.F. Tracy & E.T. O’Grady (eds)
Advanced Practice Nursing: An integrative approach, 6th Edition, St. Louis: Elsevier, pp. 61 – 79.
Hannon RA, Ray SL & Staples E (2016). Canadian perspectives on Advanced Practice Nursing. Toronto: Canadian
Scholars Press.
Hanson, C.M. Hamric A.B. Reflections on the continuing evolution of Advanced Practice Nursing. Nursing Outlook,
2003. 51(5): pp. 203-211.
Health Education England (HEE) (2017). Multi-professional Framework for Advanced Clinical Practice https://www.
hee.nhs.uk/sites/default/files/documents/Multi-professional%20framework%20for%20advanced%20clinical%20
practice%20in%20England.pdf.
Hill MN, Parker J, Liu H, Hu Y, Guo G (2017). Strategic directions and actions for Advanced Practice Nursing in
China. International Journal of Nursing Sciences, 4(1), pp. 8-11.
Horrocks S, Anderson A, Salisbury C (2002). Systematic review of whether Nurse Practitioners working in pri-
mary care can provide equivalent care to doctors. British Medical Journal, 324, 819. doi: https://doi.org/10.1136/
bmj.324.7341.819.
International Council of Nurses (ICN) (2008a). The scope of practice, standards and competencies of the Advanced
Practice Nurse. Monograph, ICN Regulation Series. Author: Geneva.
International Council of Nurses (ICN) (2008b). Nursing care continuum framework and competencies. Monograph,
ICN Regulation Series. Author: Geneva.
Irinoye OO (2011). North-South collaboration for the advancement of nursing education and quality health care in
Nigeria – Report on proposal for collaboration between University of Maryland School of Nursing, Office of Global
Health, Baltimore and Department of Nursing Science, Obafemi Awolowo University, ILE-IFE (unpublished paper).
Jennings N, Clifford S, Fox AR, O’Connell J, Gardner G (2015). The impact of Nurse Practitioner services on cost,
quality of care, satisfaction and waiting times in the emergency department: a systematic review. International
Journal of Nursing Studies, 52(1):421-35. doi: 10.1016/j.ijnurstu.2014.07.006.
Jhpiego (2016). Scope, standards, policies and procedures model. Accessed September 7, 2018 from https://
reprolineplus.org/system/files/resources/o3_SSPP%20Model_tc.pdf.
29
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
Keeling AW, Bigbee JL (2005). The history of advanced practice in the United States. In A.B. Hamric, J.A. Spross,
C.M. Hanson (Eds.) Advanced Practice Nursing: an integrative approach. 3rd Edition. St. Louis: Elsevier Saunders.
pp. 3 – 45.
Kilpatrick K, DiCenso A, Bryant-Lukosius D, Ritchie JA, Martin-Misener R, Carter N (2013). Practice patterns and
perceived impact of Clinical Nurse Specialist roles in Canada: Results of a national survey. International Journal
of Nursing Studies, 50(110), 1524-1536.
Kim MY (2011). Effects of oncology Clinical Nurse Specialists’ interventions on nursing-sensitive outcomes
in South Korea. Clinical Journal of Oncology Nursing, 15. E66-74. doi: 10.1188/11.ONF.E66-E74.
Leary A, Crouch H, Lezard A, Rawcliffe C, Boden, L, Richardson A (2008). Dimensions of Clinical Nurse Specialist
work in the UK. Nursing Standard (Royal College of Nursing), 23(15) 40-44. doi:10.7748/ns2008.12.23.15.40.c6737.
Lentz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX (2004). Primary care outcomes by Nurse Practitioners
in patients treated by Nurse Practitioners or physicians: Two year follow-up. Medical Care Research and Review,
61(3) pp. 332-351.
Lewandowski WS, Adamle K (2009). Substantive areas of Clinical Nurse Specialist practice: A comprehensive
review of the literature. Clinical Nurse Specialist, 23, pp. 73-90.
Maier C, Aiken L & Busse R (2017). Nurses in advanced roles in primary care: policy levers for implementation,
OECD Health Working Paper no. 98, OECD, Paris. doi.org/10.1787/a8756593-en.
Martin-Misener R, Harbman P, Donald F, Reid K, Kilpatrick K, Carter N, Bryant-Lukosius D, DiCenso A (2015). Cost-
effectiveness of Nurse Practitioners in ambulatory care: systematic review. BMJ Open 5:e007167 doi:10.1136/
bmjopen-2014-007167.
Miranda Neto MV, Rewa T, Leonello VM, Oliveira MAC (2018). Advanced Practice Nursing: a possibility for primary
health care? Rev Bras Enferm [internet]. 2018; 71 (Supl 7): pp. 716-721. doi: 10.1590/0034-7167-0672.
Mundinger MO, Kane RL, Lenz ER (2000). Primary care outcomes in patients treated by Nurse Practitioners or
physicians. JAMA, 283(1)59-68, doi: 10.1001/jama.283.1.59.
National Association of Clinical Nurse Specialists (NACNS) (2004). Model Rules and Regulations for CNS Title
Protection and Scope of Practice. Author: Harrisburg, PA, USA.
National Association of Clinical Nurse Specialists (NACNS) (2010). National CNS Competency Task Force:
Executive Summary, Author: Harrisburg. PA, USA.
National Association of Clinical Nurse Specialists (NACNS) (2018) What is a Clinical Nurse Specialist? Accessed
24 January 2018 from http://nacns.org/about-us/what-is-a-cns/.
National Council for the Professional Development of Nursing and Midwifery (2007). Framework for the establish-
ment of Clinical Nurse/Midwife Specialist posts: Intermediate Pathway. 3rd Edition. NCNM: Dublin, Ireland.
National Council for the Professional Development of Nursing and Midwifery (NCNM) (2008a). Profiles of Advanced
Nurse/Midwife Practitioners and Clinical Nurse/Midwife Specialists in Ireland. Author: NCNM, Dublin, Ireland.
National Council for the Professional Development of Nursing and Midwifery (NCNM) (2008b). Framework for the
Establishment of Advanced Nurse Practitioner and Advanced Midwife Practitioner Posts 4th Edition. Author: NCNM,
Dublin, Ireland.
National Organization of Nurse Practitioner Faculties (NONPF) (2017). Nurse Practitioner core competencies con-
tent. Author: NONPF.
Newhouse RP, Stanik-Hutt J, White KM, Johantgen M, Bass EB, Zangaro G, Wilson RF, Fountain L, Steinwachs DM,
Heindel L, Weiner JP (2011). Advanced Practice Nurse outcomes 1990-2008: A systematic review. Nursing
Economics, 29/5, CNE Series.
30
References
Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC) (2014). Advanced Nursing
Practice framework: Supporting Advanced Nursing Practice in health and social care trusts. Department of Health,
Social Services and Public Safety (www.dhsspsni.gov.uk).
Nursing Council for the Professional Development of Nursing and Midwifery (NCNM) (2008). Framework for the
establishment of Advanced Nurse Practitioner and Advanced Midwife Practitioner posts. 4th Edition.
NPAC-AIIPC (2018). Nurse Practitioner definition in Canada. Accessed April 4, 2019 from https://npac-aiipc.org
Nurse Practitioner Association in Canada, Nova Scotia.
Nursing Council of New Zealand (NCNZ) (2017a). Competencies for the Nurse Practitioner scope of practitioner.
Author: NCNZ.
Nursing and Midwifery Board of Australia (NMBA) (2014). Nurse Practitioner standards of practice.
Nursing and Midwifery Board of Australia (NMBA) (2018). Nurse Practitioner standards of practice (update
March 2018).
Nursing and Midwifery Board of Ireland (NMBI) (2015a) Ionising radiation, nurse prescriptive authority. Standards
and Requirements. Author: NMBI.
Nursing and Midwifery Board of Ireland (NMBI) (2015b). Prescriptive Authority for Nurses and Midwifes. Standards
and Requirements. Author: NMBI.
Nursing and Midwifery Board of Ireland (NMBI) (2017) Advanced practice (nursing) standards and requirements.
Author: NMBI.
O’Connor T (2016). So what’s a Clinical Nurse Specialist exactly? Kai Tiaki Nursing New Zealand, 22(2) pp 15-16.
Office of the Chief Nurse, Department of Health (2017). Developing a Policy for Graduate, Specialist and Advanced
Nursing & Midwifery Practice Consultation Paper. Author: DoH.
Prostate Cancer UK (2014). The specialist nursing workforce caring for men with prostate cancer in the UK.
Research report 2014. Commissioned by Prostate Cancer UK.
Royal College of Nursing (RCN) (2008). Advanced Nurse Practitioners - an RCN guide to the Advanced Nurse
Practitioner role, competencies and programme accreditation. London: Author.
Royal College of Nursing (RCN) (2010). RCN competencies-Advanced Nurse Practitioners. An RCN guide to the
Advanced Nurse Practitioner role, competences and programme accreditation. Retrieved 5 October 2018 from
http://www.wales.nhs.uk/sitesplus/documents/8.
Royal College of Nursing (RCN) (2012). Advanced Nurse Practitioners: An RCN guide to Advanced Nursing
Practice, Advanced Nurse Practitioners, and programme accreditation. London: Author.
Royal College of Nursing (RCN) (2018). RCN credentialing for advanced level nursing practice: Handbook for
applicants. London: RCN Credentialing.
Rushforth H (2015). Advanced Nursing Practice: The theoretical context and evidence base. In T.D. Barton,
D. Allan (Eds.) Advanced Nursing Practice: Changing healthcare in a changing world. London: Palgrave/Macmillan
Publishers Limited. pp. 21 – 49.
Sangster-Gormley (2007) Nurse Practitioner sensitive outcomes. Halifax: College of Nurses Nova Scotia, Canada.
Schober M, Affara FA (2006). Advanced Nursing Practice. Oxford: Blackwell Publishing Ltd.
Schober M (2016). Introduction to Advanced Nursing Practice: An international focus. Cham, Switzerland: Springer
International Publishing AG.
Schober M (2017). Strategic planning for Advanced Nursing Practice. Cham, Switzerland: Springer International
Publishing AG.
Schober M, Green A (2018). Global perspectives on Advanced Nursing Practice. In L. Joel (Ed.) Advanced Practice
Nursing, 4th Edition, pp. 55 – 89, Philadelphia: F.A. Davis.
Schreiber R, MacDonald M, Pauly B, Davidson H, Crickmore J, Moss L, Regan S, Hammond C (2005). Singing
in different keys: Enactment of Advanced Nursing Practice in British Columbia. Canadian Journal of Nursing
Leadership Online Exclusive June: 1-17.
31
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
Scottish Government (2008). Supporting the development of Advanced Nursing Practice: A toolkit approach.
Author: CNO Directorate, Scottish Government.
Seitio-Kgokgwe O, Gauld RDC, Hill PC, Barnett P (2015). Development of the national health information sys-
tems in Botswana: Pitfalls, prospects and lessons. Online Journal of Public Health Informatics. doi: 10.5210/ojphi.
v7/2.5630.
Sibanda B, Stender SC (2018). Anglophone Africa Advanced Practice Nurse Coalition Project (AAAPNC):
A Proposal to WHO (Africa) Health Systems Leadership. Unpublished document.
Steinke MK, Rogers M, Lehwaldt D, Lamarche K (2017). An examination of Advanced Practice Nurses’ job satis-
faction internationally. INR, 65(2) doi:org/10.1111/inr.12389.
Swan M, Ferguson S, Chang A, Larson E, Smaldone A (2015). Quality of primary care by Advanced Practice
Nurses: A systematic review. Int J Qual Health Care, 27(5): 396-404, doi: 10.1093/intqhc/mzv054.
Tracy MF, O’Grady ET (2019). Advanced Practice Nursing: An integrative approach, 6th Edition, St. Louis: Elsevier.
Tracy MF, Sendelbach S (2019). The Clinical Nurse Specialist. In M.F. Tracy & E.T. O’Grady (eds) Advanced
Practice Nursing: An integrative approach, 6th Edition, St. Louis: Elsevier, pp. 343 – 373.
Prostate Cancer UK (2014). The specialist nursing workforce caring for men with prostate cancer in the UK:
Research report. Author: Prostate Cancer UK.
World Health Organization-Eastern Mediterranean Region (WHO-EMRO) (2018). Regional guide for the develop-
ment of nursing specialist practice. Author: Cairo.
Woo BFY, Lee JXY, Tam WWS (2017). The impact of the Advanced Practice Nursing role on quality of care, clinical
outcomes, patient satisfaction, and cost in the emergency and critical care settings: A systematic review. Human
Resources in Health 15:63, doi: 10.1186/s12960-017-0 237-9.
Carolyn Jones
32
Appendices
APPENDICES
Appendix 1: Credentialing Terminology
CERTIFICATION The formal recognition of knowledge, skills and experience demonstrated by the
achievement of the professional standard set for the CNS or NP. Recognition of
competence for a CNS or NP who has met pre-established eligibility requirements
and standards.
EDUCATION The formal preparation of the CNS or NP: at a master’s degree or beyond that
of a generalist nurse.
LICENSURE The granting of the authority to practice. The process, sanctioned by law,
of granting exclusive privilege to CNSs or NPs meeting established standards,
which allows the CNS or NP to practice and to use the specifically protected title
of CNS or NP.
REGISTRATION In a basic sense registration means that an individual’s name has been entered
into an official register for persons who possess the specific qualifications for CNS
or NP. The register is maintained by a regulatory or another official governmental
body and usually provides title protection. The register is not a validation of
competence for the CNS or NP but simply a listing or registration of the position.
A general overview indicates that in Japan, the first The following case exemplars provide in-depth country
CNS master of nursing graduate programme was in descriptions of successful CNS development.
psychiatric/mental health nursing and graduated its
first students in 1986. By 2005, Japan had 139 nurses Canada
practicing as a CNS (Schober & Affara 2006). The first CNSs were introduced in Canada to provide highly
CNS in Taiwan was employed in 1994 in cardiac sur- complex and specialised care, develop nursing prac-
gery. The Hospital Authority of Hong Kong introduced tice, support nurses at the point-of-care, and lead qual-
the nurse specialist (not currently identified as a CNS) ity improvement and evidence-based practice initiatives
in 1994 hoping that it would motivate nurses to remain in response to research advances in treatment and
in clinical practice. In South Korea, the Oncology CNS technology (Bryant-Lukosius & Martin-Misener 2015).
began working at one South Korean hospital in 1994. Three areas of CNS practice include management and
To earn national CNS certification (established in 2005) care of complex and vulnerable populations, education
nurses must prepare at the master’s level of education and support of interdisciplinary staff, and facilitation of
and pass an examination. Early evaluation of this role change and innovation within the health-care system
provides indications of positive impact on oncology (Lewandowski & Adamle 2009). Their clinical role within
patient care (Kim 2011). The Thai perspective for the the healthcare organisation enables them to identify
CNS emphasises specialisation and expansion of nurs- care and resource gaps to improve client flow and clin
ing and has been based on the American model in six ical outcomes as well as to enhance health system pol-
specialty areas (maternal/newborn, pediatrics, medical/ icies (CNA 2019).
surgical, mental health/psychiatric, community health
and gerontology) (Wongkpratoom et al. 2010).
33
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
The CNS in Canada does not have a protected title others in their provision of direct care. In this capacity,
and standardised educational programmes are not yet the CNS participates in and implements nursing/clinical
available (Bryant-Lukosius et al. 2010; CNA 2012; CNA research, audits and provides consultancy in educa-
2019). Canadian researchers (Bryant-Lukosius et al. tion and clinical practice to nursing colleagues and the
2018) found that lack of regulation and title protection wider interdisciplinary team. CNSs are, in tandem with
poses barriers to CNS full practice potential. This situ- their line manager, responsible for their continuing pro-
ation for CNSs in Canada appears to be related to the fessional development, including participation in formal
mix of master’s- and non-master’s-educated Advanced and informal educational activities, thereby ensuring
Practice Nurses working as specialists without clear sustained clinical credibility among nursing, medical
avenues for career advancement, education, cre- and paramedical colleagues (National Council for the
dentialing, or methods for knowing which nurses are Professional Development of Nursing and Midwifery,
practicing safely at an advanced level. As a result, the 2007).
public, health care providers, and administrators are
uncertain about what CNSs have to offer and may have Japan
unclear expectations about the CNS scope of practice. The Japanese Nursing Association (JNA) established
This lack of clarity and uncertainty poses a risk for the the Clinical Nurse Specialist System in 1994 with the
recruitment and retention of CNSs despite evidence following purpose. Our goal is to contribute to the devel-
supporting the positive impact of the role in the country opment of health and welfare as well as improving nurs-
(CNA, 2019). ing science by sending CNSs with deepened knowledge
and skills in specific specialized nursing fields to the
New Zealand society and provide high level nursing care efficiently to
In New Zealand, the CNS role has no formal or legal individual, families and population with complicated and
definition thus there is confusion about the CNS and intractable nursing issues. The JNA definition of CNS
the relevant scope of practice (O’Connor 2016). The which named Certified Nurse Specialist is the person
qualifications required for a CNS to practice in New certified as a nurse with excellent nursing practice com-
Zealand vary at the discretion of employers. A study petency in a specialized field. CNSs plays the following
conducted in New Zealand, that replicated a study con- six roles:
ducted in Australia, noted that the scope of practice for • To provide excellent nursing practice to individual,
the NP and CNS may overlap but are not interchange- families and population.
able (Carryer et al. 2018). Study findings indicate that
the CNS position in New Zealand equates to the clin • To provide consultation to care providers including
ical nurse consultant in Australia and, similar to studies nurses.
conducted in Australia (Gardner et al. 2013 & 2015), • To coordinate among the concerned
are the only roles to be defined as Advanced Practice multi‑disciplinary professions to provide
Nursing roles. Carryer et al (2018) suggest that the required care smoothly.
more prevalent presence of the CNS in New Zealand • To solve ethical issues and conflict to protect the
may be related to employment practices that favor CNS right of individual, families and population.
appointments that in turn translate to opportunities for
• To educate nurses to improve care.
this type of APN practice.
• To conduct research activity in their clinical settings
Republic of Ireland to advance and develop professional knowledge
The framework for the development of the CNS in and skills.
Ireland provides the requirements for nurses seeking
this position. The CNS is viewed as a defined advanced There are 13 specialized fields as of 2018; Cancer
area of nursing practice that requires application of spe- Nursing, Psychiatric Mental Health Nursing, Community
cially focused knowledge and skills, which are both in Health Nursing, Gerontological Nursing, Child Health
demand and required to improve the quality of patient/ Nursing, Women’s Health Nursing, Chronic Care
client care in the country. (National Council for the Nursing, Critical Care Nursing, Infection Control
Professional Development of Nursing and Midwifery Nursing, Family Health Nursing, Home Care Nursing,
2007). Genetics Nursing, Disaster Nursing are identified.
The JNA certifies nurses as CNS upon completion of
The practice of a CNS includes a focus which consists the CNS curriculum in the master’s programme, and
of assessment, planning, coordination and provision passing the certificate examination given by JNA. The
of care, health promotion and patient education. They title of CNS is protected by trademark registration and
also communicate and negotiate decisions in collab allowed to use it by the nurses who are certified by JNA.
oration with other healthcare professionals and commu- CNSs contribute to improve quality of nursing in their
nity resource providers. CNSs represent patient/client clinical settings and community by providing not only
values in hospital, community and outpatient settings. direct care but also through consultation, education,
The CNS works closely with medical and para-medical coordination and ethical coordination to nurses and
colleagues and may make alterations in prescribed multi-disciplinary professions. Moreover, CNSs contrib-
clinical options along agreed protocol driven guide- ute to develop efficient care by accumulating evidence
lines. Specific responsibilities are represented in a job through research (Japanese Nursing Association).
description rather than the position title.
34
Appendices
35
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
The NP scope of practice is built on the basis of the commonly in nurse/NP managed clinics. Even though
registered nurse (RN) scope of practice and must there is success in the country, there is still a need for
meet the regulatory and professional requirements for stronger policies and regulatory systems to support the
Australia including the Registered nurse standards for NPs (Seitio-Kgokgwe et al. 2015).
practice and Code of conduct for nurses. The NP stand-
ards build on and expand upon those required of an Canada
RN. The NP is expected to understand the changes in In Canada, the only Advanced Practice Nursing role with
scope of practice from the RN and the ways that these additional regulation and title protection beyond that of
changes affect responsibilities and accountabilities the generalist nurse is the NP. NPs can autonomously
(NMBA 2018). make a diagnosis, order and interpret diagnostic tests,
prescribe pharmaceuticals and perform specific pro-
Anglophone Africa APN Coalition cedures within their legislated scope of practice (CNA
Under the title ‘Anglophone Africa Advanced Practice 2009). The Nurse Practitioner Association of Canada
Nurse Coalition Project (AAAPNC): A Proposal to (2018) offers the following definition:
WHO (Africa) Health Systems Leadership’ (Sibanda &
Stender, 2018) five countries have set a priority to initi-
ate Family Nurse Practitioner (FNP) programmes and
to start work on midwifery advanced practice by the In Canada, Nurse Practitioners (NPs) are licensed by
end of 2020. Strong support for this initiative is being jurisdictional nursing regulators. NPs are graduate pre-
provided by experts and universities in the UK and the pared health care providers who practice autonomously
USA. To achieve the aims of the project, the intent is and independently. NPs provide direct care to patients
to instigate robust research developing Afrocentric to diagnose and manage disease/illness, prescribe
models and frameworks relevant to population needs medications, order/interpret laboratory/diagnostic tests
and healthcare systems. In addition, the intent is to and initiate referrals to specialists.
collaborate with representatives in medicine, phar-
macy and other healthcare disciplines. In a gesture of
support, LeadNurseAfrica dedicated its April 2019 pre- (NPAC-AIIPC 2018)
conference workshops in Ghana to Advanced Practice
Nursing. Following a federally funded initiative (Canadian NP
Initiative) a framework for the integration and sustain-
African universities that have agreed to participation ability for the NP role in Canada’s healthcare system
in this initiative include: Aga Khan University sites in was developed. NPs now practice in a wide variety of
Kenya, Uganda and Tanzania already in advanced settings and in various models of care. The NP scope
stages of the development of MScN (APN) curriculum of practice is defined along with a common role descrip-
in collaboration with the Nursing Council of Kenya; tions and liability coverage. The country continues to
University of Botswana, the only African institution work to remove federal and legislative barriers for distri-
with a master’s degree for the FNP that matches inter bution of medical samples, medical forms for disability
national APN standards in education, accreditation and claims and workmen’s compensation (CNA, 2016).
regulatory practice; and The School of Nursing and
Midwifery, University of Ghana. Caribbean Region
Following the example of the NP in the USA and
The concept of Advanced Practice Nursing has been through the assistance of the Pan American Health
identified in South Africa, Kenya, Zambia, Malawi, Organization and Project Hope, NP education began in
Swaziland, Botswana, Uganda and Rwanda, but the Jamaica in 1977, and in St. Vincent (discontinued 1987)
scope of practice and legislation to formalise their and the Grenadines. In St Lucia, Dominica, St Vincent
respective practices are not explicit (Sibanda & Stender and the Grenadines, NPs have prescriptive authority for
2018) and in most African countries achieving the inter- some drugs and practice mainly in PHC settings with
national standard of master’s degree education is still prescriptive authority guided by a specific formulary. In
aspirational. St. Vincent and the Grenadines and St Lucia, NPs have
the autonomy to develop their own itineraries. As of
Botswana 2017, 72 NPs in Jamaica provide healthcare services,
Country independence, a need for health care reform mostly in rural areas. Often, they are given pre-signed
and a shortage of physicians triggered the need for scripts and sometimes required to run the clinics alone.
nurses to accept increased responsibilities for PHC in
Botswana, but the nurses ultimately demanded add In the Caribbean Region, the role of the NP is clearly
itional education to accomplish this. The first Family defined. Education for NPs is offered only at University
Nurse Practitioner (FNP) programme was established of the West Indies School of Nursing in Jamaica. The
at the Institute of Health Science in 1981 followed by master’s degree two-year programme is not funded by
revisions of the curriculum in 1991, 2001 and 2007. the government. Therefore, some nurses are unable
Candidates must have: 1) a qualified nursing degree, to access the education due to cost incurred. Upon
2) minimum experience of two years as a nurse, 3) be completion of the programme NPs are given their
registered with the Nursing and Advance Diploma in job description which outlines their scope of practice.
Midwifery Council of Botswana, and 4) be in posses- Monthly work schedules are assigned by the Medical
sion of a Botswana General Certificate of Secondary Officer, Senior Public Health Nurse or identified by
Education or its equivalent. In addition, the University of the NPs themselves. Continuing education forms the
Botswana offers a master’s programme for the FNP with framework for NPs to update their knowledge base with
efforts in process to join components of the two FNP seminars held monthly.
educational options. Nurse Practitioners in Botswana
provide primary care in outpatient departments, clin-
ics, industrial settings, schools, private practice, and
36
Appendices
Even though Jamaica has been the leader in NP edu- Republic of Ireland
cation and practice in the region, the issue of lack of In Ireland, the Advanced Nurse Practitioner (ANP)
legislation continues to pose a challenge. In St. Lucia, emerged as a result of the Commission of Nursing
NPs are given a separate registration/licence while report, which recommended this development in 1998
other NPs in the region are required to use their regis- (Government of Ireland 2008). The first ANP post in
tered nurse/midwife licence to practice. Amendment of Minor Injury Emergency Care was accredited in 2002
the Nursing and Midwifery Act is underway in Jamaica (National Council for the Professional Development of
and the Bahamas since 2018. The greatest opposition Nursing and Midwifery, 2008a). Since then, the ANP
is from the medical fraternity (personal communication, presence continues to develop. The intention is to
H. McGrath, March 2019). establish a critical mass of approximately 700 ANPs by
2021, which goes towards the target of 2% of ANPs
New Zealand within the nursing workforce (Office of the Chief Nurse,
The first NP in New Zealand was endorsed in 2001. Department of Health 2017). To facilitate this develop-
Title protection was initially established through trade- ment, the Nursing and Midwifery Board of Ireland (NMBI)
marking, but the trademarking concept is no longer in published National Standards and Requirements for the
effect. In 2015, the Nursing Council of New Zealand Education of ANPs at master’s level at the end of 2017.
(NCNZ) removed the requirement that restricted NPs to Standards and Requirements for prescriptive authority
a specific area of practice and introduced a new more had already been in place (NMBI 2015a and 2015b).
general scope of practice. NPs in New Zealand must ANP core competencies in Ireland include: (1) auton-
have: 1) a minimum of four years of clinical experience omy in clinical practice, (2) expert practice, (3) pro-
prior to entry into an educational programme, 2) com- fessional and clinical leadership, and (4) research
plete an approved master’s degree programme that (National Council for the Professional Development
includes advanced practice and prescribing competen- of Nursing and Midwifery 2008b). The title Registered
cies, 3) pass an assessment against NP competencies Advanced Nurse Practitioner (RANP) is protected
by an approved panel, and 4) register with the NCNZ through the NMBI.
(Schober & Green 2018).
United Kingdom (UK) (England, Northern Ireland,
Oman Scotland, Wales)
The idea of the Advanced Nurse Practitioner (ANP) The first nurses graduated from the Royal College of
in Oman was inspired by a 2000 meeting of repre- Nursing (RCN) Nurse Practitioner programme in 1992
sentative countries of the World Health Organization- (RCN 2008). The first 15 students led the way for NPs
Eastern Mediterranean Region (WHO-EMRO) focused who now practice throughout the UK. During the early
on advancing nursing capacity and nurse prescribing. formative years as RCN developed an accreditation
The primary motivation for the ANP in Oman was a system for educational institutions, the first UK educa-
shortfall of physicians especially in PHC settings both tional competencies emerged (Barton & Allan 2015).
in number and expertise. In addition, emerging health Those competencies were based on consultancy skills,
problems, increased life expectancy and a desire to disease screening, physical examination, chronic dis-
move care closer to the population and deeper into the ease management, minor injury management, health
community caught the attention of the Ministry of Health education and counseling. The RCN competency
(MOH). The MOH and Directorate of Nursing were also framework (2008) provided criteria for new courses with
aware that nurses, out of necessity, in small healthcare these baseline competencies establishing a standard
centres were providing services in an extended scope for ANP practice outcomes (Barton & Allan 2015).
of practice and beyond the level of their generalised
nursing education. Following a series of situational ana Following devolution, the four countries of the UK
lyses by short term WHO consultants and development (England, Northern Ireland, Scotland, Wales) devel-
of a strategic direction by the Directorate of Nursing oped their own approaches to health and social care
based on recommendations by a multidisciplinary task and therefore also to associated workforce policy
force, it was decided to proceed with the APN concept regarding Advanced Practice Nursing. As a result, the
along with on the job training (OJT) for nurses in health NP developed in different ways and educational prepar
centres already functioning in an advanced clinical ation ranges from a generic approach to a growing ten-
capacity. dency to establish preparation at the master’s degree
level. Despite enthusiasm for the role, regulation for
The first ANP, educated in a USA NP master’s degree ANP has not been established in the UK.
programme, began practice in Oman in 2016. Since
that time, additional nurses have completed pro- There is a move to a wider perspective of Advanced
grammes abroad and at Sultan Qaboos University. The Clinical Practice (ACP) emerging in the UK since 2017
ANPs practice in their field of expertise and/or teach in (HEE, 2017). Identifying with ACP incorporates a wide
the College of Nursing, SQU. The OJT for nurses prac- range of non-medical healthcare professionals within
ticing beyond their scope of practice was implemented the multiprofessional ACP category extending to allied
in 2017 with 25 nurses enrolled from all governorates health professionals. Therefore, use of ‘advanced’ titles
of Oman. Based on this success, the trajectory for vary within and across institutions. England has taken
these nurses is to support them from their extended this further to include pharmacists and social workers.
role based on OJT to progress to the specialist role In Scotland, there are separate nursing and paramedic
(Bachelor in Community Health Nursing) and then to work streams and work has started to widen to other
the ANP role with a focus on family health (personal allied health professionals. The focus in Northern
communication, M. Al-Maqbali, April 2019). Ireland is currently nursing but discussions have started
regarding expanding this to allied health professionals
(personal communication, K. Maclaine, 8 March 2019).
37
GUIDELINES ON ADVANCED PRACTICE NURSING 2020
In a September 2018 briefing, the Council of Deans of Northern Ireland: Northern Ireland published an
Health (2018) in the UK provided a briefing paper to Advanced Nursing Practice framework in 2014
identify UK country differences: (NIPEC 2014) to provide clarity about the Advanced
Nurse Practitioner role. The framework is intended
Wales: A framework for Advanced Nursing, to act as a guide for commissioners, workforce
Midwifery and Allied Health Professionals Practice planners, executive directors of nursing, educa-
in Wales was developed in 2010 and reviewed in tion providers, employers and managers of nurses,
2012. This framework derived content and built on including nurses themselves. Education require-
Scotland’s advanced practice toolkit for nursing ment is through a master’s programme including
(2008), including the supporting principles. In align- a non-medical prescribing being an essential com-
ment with ACP, Wales has seen the emergence of ponent. The graduate receives an award title, for
many advanced practice roles. example, an ‘MSc in Advancing Practice Education
in [Profession]’.
Scotland: Scotland has had an advanced practice
toolkit since 2008 and a framework for Advanced Western African Sub-region
Nursing Practice since 2012. Scotland has devel- The idea of having an APN programme in the Western
oped a national approach to Advanced Nurse African region has been considered for some time but,
Practitioner (ANP) education based on expect as of April 2019, this is still aspirational with proposals
ations identified in 2017 by the Transforming not reaching a logical conclusion (personal communi-
Nursing Advanced Practice Group. The country cation, April 2019, O. Irinoye). There was an attempt
has a goal to develop an additional 500 Advanced to start an APN programme in Nigeria in 2011 work-
Nurse Practitioners over the coming years with ing with stakeholders in Nigeria and the University of
funding support of the Scottish Government. Maryland, USA (Irinoye, 2011). The hope was for three
universities to incorporate the Family Nurse Practitioner
England: The Multi-professional Framework for (FNP) Programme into postgraduate programmes. The
Advanced Clinical Practice (ACP), published in initiative has been stalled due to funding issues and
2017, is expected to be implemented in 2020. The the need to work on policy dimensions for introducing
ACP framework sets out an agreed definition of ACP this new cadre of nurses into the healthcare workforce.
for health care professionals to work at a higher However, discussions have resumed with the intention
level from initial registration. Currently, advanced to include FNP content into the current revision of the
practice is not regulated in the UK, therefore Health postgraduate programme to benefit nurses who are in
Education England (HEE) are developing an or plan to start private practice.
Academy for Advancing Practice for governance of
education and quality of healthcare services.
38
Appendices
In 1997, the role was an initiative of a hospital, the Following completion of a two-year master’s pro-
University Medical Center in Groningen to improve gramme, graduates must complete a minimum of a
nursing care at an advanced level. A new healthcare act one-year structured internship and pass the national
ended the act that prohibited medical care by nonphys licensing examination, objective structured clinical
icians. This opened the possibilities to create a position examination (OSCE), before applying for APN certifi-
for nurses to provide complex healthcare services for cation, licensure and registration with the Singapore
a well-defined group of patients to improve continuity Nursing Board (SNB). All APNs must meet minimum
of care. The first master’s programme at the Hanze clinical practicum hours and achieve required CNE
University of Applied Science commenced at the end points for annual renewal of their APN practice licenses
of 1997 with 16 students using a USA programme as with SNB.
a model. The vision of the APN gained strength and
within a few years nine universities of applied science SNB details the APN scope of practice and core com-
offered the master’s programme combining theory and petencies for APNs. The core competencies are organ-
practice (P.F. Roodbol in Schober, 2017). Development ised into four domains. They are professional, legal and
from 1997 to 2019 is largely due to support from the ethical nursing practice; management of care; leader-
Dutch government. ship and management; and professional development.
Each competency domain has associated competency
Even though the concept of ‘Nurse Practitioner’ was standards, with each standard representing a major
known in the Netherlands, the title was not translatable function/functional area to be performed by an APN.
to Dutch thus the title NP was not protected, therefore
the only possibility in the law was to establish legis- In 2018, the Singapore Ministry of Health, NUS Alice
lation for specialisation. Using the title ‘nurse special- Lee Centre for Nursing Studies and the NUS pharmacy
ist’ in Dutch, it became possible to protect the title and department co-developed and co-hosted the three-
establish a registration process. Title protection allowed month national collaborative prescribing programme
for identification of the role with the consequence of (NCPP) to prepare APNs and pharmacists for pre-
malpractice removal from the register with no possi- scribing under a Collaborative Practice Agreement with
bilities to continue to practice if a nurse misrepresents medical practitioners. The programme is offered twice
his or her position in the healthcare system. Factors a year. As of April 2019, 74 APNs and pharmacists
that have promoted progress in the Netherlands are have completed the programme, and received or were
a clear definition of Advanced Practice Nursing, legal waiting to receive the authority licenses to prescribe
registration (title protection) and credentialing to offer medications without the requirement of physician sig-
safe and responsible care and cure (P.F. Roodbol in natures (www.pharmacy.nus.edu.sg/national-collabora-
Schober 2017). As of February 2016, approximately tive -prescribing/) (personal communication April 2019,
2,750 nurse specialists have been educated and regis Zhou Wentao, NUS Programme Director (Master of
tered in the country. The shortage of physicians that Nursing).
prompted the introduction of the role in the Netherlands
has been resolved, but the numbers of nurse special-
ists continue to increase. These nurses are accepted
as a professional that provides high quality care and
friendly advice (J. Peters in Schober & Green 2018).
Singapore
The Advanced Practice Nurse (APN) is a protected title
in Singapore, and the APN role is a hybrid of the NP
and CNS role. The National University of Singapore
(NUS), under the auspices of the Yong Loo Lin School
of Medicine, established the master of nursing pro-
gramme in 2003. Since then, this is the only programme
accredited by the Singapore Nursing Board (SNB) to
provide APN education, and it is a pre-requisite for APN
certification. The programme initially offered academic
preparation in adult health and mental health. In 2009,
offerings were extended to a critical care track and sub-
sequently a pediatric track was offered in 2012.
39
International Council of Nurses
3, Place Jean Marteau
1201 Geneva, Switzerland
+41229080100
icn@icn.ch
www.icn.ch